Selecting, adapting, and sustaining programs in health care systems

Figures & data

Table 1 Determining appropriateness for scale-up

Case study: Dr Smith and her postdoctoral student, Jane, developed an intervention to improve medication adherence for elderly patients with hypertension. Their intervention was developed after a careful review of existing scientific literature and had a sound theoretical basis (ie, KTA knowledge creation: knowledge inquiry and synthesis phases). Dr Smith presented her intervention idea to hospital leadership while designing the intervention to secure their buy-in. The intervention involved a pharmacist providing telephone-based behavioral counseling and medication management at monthly intervals (ie, KTA knowledge creation: products/tools phase). While the primary outcome was blood pressure control, Dr Smith also collected information on changes in medication adherence throughout the course of the study. Information about the length of the phone calls, cost of the intervention, and acceptability from both a pharmacist and patient perspective were also collected. The study enrolled 100 elderly patients with hypertension from a single medical center. Half of the patients were randomized to the intervention and half to their usual care. The intervention was a success. Patients in the intervention group had significant improvements in blood pressure control and medication adherence (ie, KTA action cycle: evaluate outcomes). Patients and providers alike reported that the intervention was worthwhile; however, it was not cost-effective. Dr Smith and Jane conducted additional analyses and hypothesized that, although the intervention is costly in the short-term, there would be long-term cost savings as a result of improved blood pressure control (eg, fewer heart attacks and hospitalizations). Hospital administrators were impressed with the study findings and approached Dr Smith about scaling up the intervention for delivery at two other hospitals in the health care system. They were aware that the intervention was not cost-effective, but appreciated it for its simplicity and indicated that they could fund the program for 1 year.

Thoughts to consider

• Has the intervention been proven beneficial to patients? Are there potential harms?

• Are the improvements in medication adherence and blood pressure control maintained over time?

• Is there new knowledge worth translating into action?

• What alterations would need to be made if the intervention is scaled up to the health care system?

Abbreviation: KTA, Knowledge to Action.

Table 2 Allowing for flexibility in design

Case study: Dr Smith partners with hospital leadership to expand the intervention to three hospitals in the health care system. As part of this transition, it becomes part of clinical practice. Dr Smith is concerned about the fidelity to the original intervention content. The team institutes ongoing monitoring by recording telephone calls and conducting continuing education with participating pharmacists (ie, KTA action cycle: monitor and sustain knowledge use). Dr Smith identifies a problem; some pharmacists are excluding an educational component about the importance of daily home-based blood pressure monitoring. A review and brief retraining are conducted (ie, KTA action cycle: identify problem, review). During the training, several pharmacists tell Dr Smith that they are skipping this content because patients do not have tools to monitor their values at home. Dr Smith modifies the intervention content to include local information about where free blood pressure monitors are available, such as at local drugs stores (ie, KTA action cycle: adapt knowledge to local context). She talks with the intervention pharmacists to assess whether they are comfortable discussing this information with patients (ie, KTA action cycle: assess barriers to knowledge use). Over time, additional modifications are made for the local context. To reduce the cost of the intervention and save pharmacists’ time, instead of providing individual telephone-based counseling the intervention is delivered to two patients at a time via a “buddy” conference call. In addition to receiving the original intervention content, patients report liking the social support aspect of the intervention.

Thoughts to consider

• Is it appropriate for Dr Smith to change the intervention content during intervention delivery?

• How could Dr Smith have included stakeholders in the ongoing monitoring and evaluation process?

• How could the intervention content or delivery be tailored for this patient population or clinical context?

Abbreviation: KTA, Knowledge to Action.

Table 3 Adapting interventions

Case study: Dr Smith’s intervention is successful throughout the three-hospital health care system. Thanks to cost savings and buy-in from organizational leadership, the intervention delivery is ongoing after a year. She has published several articles describing the intervention development, implementation, and dissemination. Dr Smith’s former postdoc, Jane, is now running a medication adherence clinic in another state. She reads about the success of Dr Smith’s intervention in “real world” clinical practice and considers whether it would benefit patients in her clinic, but she wonders whether it is feasible in that setting. Nurses staff Jane’s clinic; she does not have access to pharmacists. Also, all of the patients receiving care in Jane’s clinic are given a Wi-Fi-enabled blood pressure monitor as part of their routine clinical care so providers know patients’ home-monitored blood pressure values in real-time. Jane is not sure how these differences might impact the integrity of the intervention. Would it still help her patients? Dr Smith’s publications do not provide any insight into whether she thinks changing the role of the interventionist will change the clinical outcome. Jane decides to contact Dr Smith and seek her insight.

Thoughts to consider

• What are the core components of Dr Smith’s original intervention?

• Did the core components remain consistent as the intervention was translated from a research study (Table 1) to clinical practice (Table 2)?

Table 4 Sustaining interventions

Case study: Jane speaks with Dr Smith and is confident in her clinic’s ability to adapt and implement the intervention. Jane is focused on designing and implementing the intervention so that it can be sustainable in the long-term. She immediately begins planning for the intervention implementation. She gathers relevant evidence by reviewing scientific literature, speaking with Dr Smith, and meeting with leaders at other sites that have implemented the intervention. Next, she seeks the commitment and support of top leaders in her organization, as well as front-line clinic staff. In doing this, Jane develops partnerships both internal and external to the clinic. She cultivates a partnership with a blood pressure monitor manufacturer and a local patient advocacy group. She also identifies program champions within her institution; there are two nurse managers who are very enthusiastic about the program. Jane wants to build capacity to carry out and sustain the intervention, so she invests in training for clinic staff in how to educate patients to use their monitors and in the intervention content. She goes a step further by having train-the-trainer sessions, so that in the future her own staff can train those who are new to the clinic. Jane plans ahead and meets with her organization’s administrators. They agree that, if the intervention is successful and is cost-effective, it may be possible to embed the intervention into the organization’s core policies. However, Jane must ensure that the intervention effectiveness and outcomes are evaluated on an ongoing basis. While Jane is keen on implementing the intervention and planning for sustainability, she recognizes that the program may have to evolve and adapt in order to stay viable. She plans to re-evaluate key aspects of the intervention delivery at 6-month intervals. In doing this Jane plans to develop a report, along with the program champions and key stakeholders, to secure future funding. She plans to request funding from the blood pressure monitor manufacturer that has agreed to partner with the clinic on the project, as well as a foundation that offers funds to improve patient care.

Thoughts to consider

• What additional steps could Jane take to encourage intervention sustainability?

• Are there other partnerships that Jane needs to develop?

• How could she keep key stakeholders, partners, and program champions engaged with the intervention?

• Is there a role for an advisory board or committee for sustainability?

Figure 1 Putting it all together – suggestions for sustainable programs.

Notes: The phases in Figure 1 need not be sequential. For example, it is possible to move from the planning phase, to the doing phase and the study phase, determine that the intervention is not cost-effective, and then cycle back to the planning phase.